MEDICARE: JAMES R OUELLETTE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	34007386	OH
2	2086X0206X	Surgical Oncology Physician	340073869	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245288422
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES R OUELLETTE DO

Provider Business Mailing Address
First Line	:	3170 KETTERING BLVD BLDG B3
Second Line	:
City	:	MORAINE
State	:	OH
Zip	:	45439-1924
Country	:	US
Telephone Number	:	937-991-3191
Fax Number	:	937-223-9811

Provider Business Practice Location Address
First Line	:	2300 MIAMI VALLEY DR
Second Line	:	SUITE 350
City	:	CENTERVILLE
State	:	OH
Zip	:	45459
Country	:	US
Telephone Number	:	937-424-2469
Fax Number	:	937-424-2479

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	08/01/2018

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